Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”
A humorous and telling story about quality measurement, decision support, and human nature:
I was visiting professor at a very good academic medical center a year or so ago. On these trips, one of the fun things I get to do is meet with the residents. Sometimes they present a clinical case to me, but this day they wanted to talk about healthcare policy. So I thought I’d check out what they knew about the new world of quality measurement and transparency.
“Who admitted a patient with pneumonia last night?” I asked the bleary-eyed, overcaffeinated group of 20 somethings, each looking only slightly older than my kids. Three interns hesitatingly raised their hands.
“If I wanted to figure out whether you provided high quality care,” I continued, “what should I look at?”
“I think we saved this guy’s life,” one beamed. “Yeah, and I had a lady who was confused, hypotensive, and hyperglycemic,” said another, “and we did a really good job taking care of her. She’s much better this morning.”
“That’s great,” I said, “but your quality is actually being measured in a different way. Here are the things that insurers and the government are looking at – did you give pneumovax and flu vaccine, did you document smoking cessation counseling, did you obtain blood cultures in the ED, did you check an oxygen saturation, did you give guideline-recommended antibiotics, and did you give the antibiotics promptly? What do you think?”
“Well, those are important, I guess,” one intern said haltingly.
“Now,” I pressed on, “you should also know that your performance on these measures is posted on the Web. Would you” – I pointed to a resident half-dozing by a computer terminal – “mind going to this site (Medicare’s "Hospital Compare"), type in our zip code, and let’s see what happens.”
And she did. We quickly navigated to the hospital’s pneumonia performance, put in a few local comparison hospitals (read: competitors), and saw that the hospital wasn’t doing particularly well – at the mean on a few of the measures, below it on others.
“Now let’s say that you were the czar of quality at this hospital,” I said, fully knowing that the Director of Quality was sitting, slightly red-faced, in the back of the room, “and you saw these results. What would you do to try to improve the performance?”
“I’d give the residents a lecture on pneumonia and quality.”
“Naw, that wouldn’t do anything. Maybe they should buy us a nice lunch!” The group giggled.
“No, I’ve got an idea,” excitedly said a third. “When you admit somebody with pneumonia and start to enter your orders into the computer system” – this was one of the 15% or so of U.S. hospitals with computerized provider order entry – "then the computer could remind you to give the pneumovax and flu vaccine.” I was impressed – they had stumbled onto the premise behind clinical decision support, the Holy Grail of the quality movement. But before I could open my mouth to endorse this strategy, another resident, one of the docs who had admitted a pneumonia patient the previous night, sprang to life…
Oooooh,” she gushed, “I actually think that happened!” I asked her what she meant. “When I admitted my patient last night,” she continued breathlessly, “I remember a pop-up box that said something like, ‘Did You Remember To Give Pneumovax?’”
“Wow,” I said, “so what did you do?”
“Oh, I clicked out of it. I was too busy last night – I got creamed, 9 admits!”
The quality officer in the back nearly seized.
“Well, that’s interesting,” I went on. "I see how that could happen. So let’s
say you’re the quality czar and the interns are ignoring your hard-fought-for pop-up messages. What would you do then?”
“I’d email the intern any time he clicked out of one without giving the medicine.”
“Nah, that would be a waste of time. The ‘terns never read their e-mail.”
“I got it,” said a thin guy in scrubs in the back row. “When the interns don’t follow the guidelines, I’d send a letter” – amazing how, in the e-mail era, letters now have the gravitas formerly reserved for telegrams – “to the Chief Residents!”
The Chief Residents are the Gods of any residency program: part-psychotherapist, part-camp counselor, part-Sensei. So this was a great idea: if the CRs knew that the interns weren’t with the program, they’d make things right before you could say William Osler.
Oooooh,” said the Chief Resident sitting to my left. “I’ve been getting all these letters for the past few months.”
“And what do you do with them?” I asked, anticipating the answer.
And with that, she slowly, deliberately, pointed to a corner of the room, where there was a barely touched pile of letters, about 3 feet high.
It’s been a while since this episode. I’m hoping the Quality Director has recovered. This quality thing is not as easy as it looks.
Bob Wachter blogs at Wachter’s World.
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I’m a subscriber of your RSS feed. In the feed, I’m gtntieg the link to digg so that I’ve to click the digg link & then read the content here.Put direct links to your articles than to digg !
My hospital has strep pneumo and influenza vaccines incorporated into its computerized orderset. When somebody gets admitted with PNA based on a computer entry, pneumovax and flu are included in the order set that the nurses get, along with O2 sats every 4 hours, oxygen, and a recommended antibiotic and dosing regimen.
At the old paper based systems, its a pain in the ass to write all those orders out separately, plus when its 3 AM and you’ve been up for over 36 hours admitting 15 patients in a row, its hard to think straight and remember to include all of that stuff.
Computerized order entry is really a hugely powerful thing here.
What are the root sources of the problem?
1. Is it an issue of time and distraction: Docs are too busy doing other things to comply with the guidelines? If so, then lessening their workloads would help.
2. Is it a matter of ego and ignorance: Docs believe that know all they have to know, so the decision tools are simply dismissed as unnecessary? If so, then they ought to be enlightened about the limits of the human mind and given incentives to change their ways.
3. Is it about current day clinical decision tools and/or quality metrics are too immature: Docs believe they will have worse (or no better) outcomes by complying with the recommendations because they are invalid or unreliable? If that’s the case, then we should be investing more in improving them.
The first issue reflects a care delivery system problem, which could be addressed by transforming our current low fidelity healthcare system to a high fidelity one.
The second is a personal issue involving both psychological and knowledge-related factors. Self-reflection, open-mindedness and education are needed here, as well as carrots and sticks.
The third is an R&D issue that could be addressed by more and better collaboration between providers, researchers and HIT developers.
Thanks for this thought-provoking and entertaining post! The links were very helpful. A few comments:
1) The quality measures currently being tracked do not distinguish between those interventions important upon admission, such as measuring oxygen saturations, as opposed to sometime during hospitalization, such as counseling re:tobacco cessation. Discussing tobacco cessation with an acutely ill patient in the ED is generally a waste of time.
2) A much more global concern: Do these quality measures actually measure quality? Or they merely variables that can be relatively easy measured and tracked and are thought (by whom?) to demonstrate high-quality care?
3) Another global concern: Do these quality measures make any difference in patient outcomes? Is there any data?
4) Does the reporting of these quality measures represent better adherence or just better documentation of these measures by individual hospitals?
5) In the typical fast-paced, high patient volume setting of the acute hospital, I believe that clinical decision support, whether computer or paper-based, is critical. I agree with docanon that standard protocols and order sets that require clinician input to override the default option are probably more effective than a pop-up reminder. This will p*** off some of the more senior physicians but I believe the overall goal of improving and standardizing patient care is well worth the risk.
If this weren’t so tragic, it would be humorous.
docanon says:
> Why not just have an automatic pneumovax
> order that cannot be rescinded?
Excellent question. What legal and attitudinal reforms would have to be accomplished to make this possible?
t
The latent error here is focusing on the behavior of individual doctors…the pop-up screen is just another variant of “try harder.” Why not just have an automatic pneumovax order that cannot be rescinded? If the patient has already had a pneumovax or has a contraindication, he or she will tell the nurse (who will have a list of questions to ask–typical right patient, right drug stuff–before giving the shot). If the patient cannot communicate and the immunization history is unknown, then a few unnecessary shots will be given…but errors of commission are presumably better than errors of omission in this case (otherwise, there’s a problem with the measures).
Another useful way to look at the problem is to ask what hospitals that do better on the measure are doing differently from hospitals that do worse. Nobody at the conference you describe was in a position to answer this question…except maybe the quality officer (who you would hope talks to quality officers from other institutions).
Holy Cow. I’m not surprised to hear that kind of “I can’t be bothered” indifference from older physicians who are more cynical and set in their ways, but I got a big sinking feeling when reading that the next generation of doctors is set to fail when it comes to public health quality measures (as opposed to ED heroics). What bothers me most is not that they cut corners to save time, but that they seem like they have never given this stuff a second thought.
Thanks for the sobering insights, though I come away feeling more than ever that our tools to improve quality are impotent. And a big part of my job is to find ways to improve quality through HIT!
Thank you. I know a little bit better what I (and we) are up against.